Brooke Knoll Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Avon, Indiana.
- Location
- 1108 Kingwood Drive, Avon, Indiana 46123
- CMS Provider Number
- 155814
- Inspections on file
- 24
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Brooke Knoll Village during CMS and state inspections, most recent first.
A resident with traumatic brain injury, dysphagia, known weight loss, and total dependence on G-tube nutrition had tube feedings that were not administered per physician orders. Surveyors observed the feeding pump not running with a partially full bag of IsoSource 1.5, despite an active order for Glucerna 1.5 at a specified rate and schedule, and no prior order allowing formula substitution. Later, the resident was connected to the tubing but the pump remained off, with minimal change in the volume of formula. The UM stated the feed was stopped because it was past the ordered stop time, while the DON reported that formula substitutions required NP approval and could only occur if the ordered product was unavailable, and the LPN reported that the time on the bag reflected when the feeding was started.
A resident’s suction canister was found about half full of yellow-tinged liquid with yellow sediment, and the canister label showed it had not been changed for an extended period despite facility policy requiring weekly and PRN changes. The ED reported the canister had been changed that day, which conflicted with the date on the canister and demonstrated failure to follow the facility’s infection prevention and control procedures for suction equipment.
A QMA was observed storing a resident's Tramadol tablets outside of their original labeled container by placing them into multiple pill crusher sleeves, some of which were stapled together and contained pills from different bottles. This practice was acknowledged by the ED as not following facility policy, which requires drugs to remain in their labeled dispensing containers and prohibits transferring medications between containers.
The facility failed to respect residents' privacy and dignity by not knocking or announcing themselves before entering rooms. A resident reported feeling disrespected, and during a Resident Council Meeting, several residents expressed similar concerns. Observations confirmed staff entering rooms without knocking, contrary to the facility's policy on Residents' Rights.
The facility failed to properly label and date medications on three of six medication carts, affecting multiple residents. Issues included insulin pens and nasal sprays without opening dates, and bottles of Tylenol and fish oil lacking labels. The Nurse Consultant acknowledged the difficulty in managing medication storage.
A facility failed to follow infection control measures during a nasal spray administration, as an LPN did not perform hand hygiene or use gloves. Additionally, the facility did not ensure consistent Enhanced Barrier Precautions (EBP) for residents with specific medical needs, as PPE was not accessible and signage was inadequate or missing, contrary to facility policy.
A resident with a history of kidney transplant and insomnia was repeatedly woken up too early for lab draws, despite expressing his preference for later timing to multiple staff members. The facility's policies on resident choice and timely lab draws were not effectively implemented, as evidenced by the resident's care plans lacking interventions for his lab work preferences.
A facility failed to conduct a new PASARR screening for a resident after a new diagnosis of bi-polar disorder was added to their medical record. The resident had multiple diagnoses, including dementia and major depressive disorder, and had previously undergone a Level I PASARR screening. Despite the addition of the new diagnosis, the facility did not determine if a Level II evaluation was necessary, contrary to their policy requiring notification of state authorities after significant changes in a resident's condition.
The facility failed to prevent potential accidents by leaving medications unattended at the bedside for two residents. A resident with multiple diagnoses was found with a cup of pills left unattended, and another resident reported a pill on the floor next to her bed from the night shift. The facility's policy requires residents to be observed taking medications and prohibits leaving medications in rooms without written authorization.
The facility failed to provide trauma-informed care for two residents with PTSD. One resident, with a history of trauma and depression, lacked a personalized care plan addressing her mental health needs. Another resident, with severe PTSD from past trauma, had an extensive but non-individualized care plan, and her preference for female caregivers was not documented. The facility's policies on trauma-informed care were not effectively implemented, leading to inadequate support for these residents.
A facility failed to follow up with pharmacy recommendations in a timely manner for a resident with multiple diagnoses, including palliative care and hypertension. The pharmacy recommended dosage reductions for aspirin and gabapentin, but the physician's response was delayed beyond the facility's 3-day policy. The DON indicated that recommendations were resent if no response was received within the specified time.
Failure to Administer G-Tube Feeding per Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident who received all nutrition via G-tube was provided tube feedings in accordance with physician orders. Surveyors observed that the resident’s feeding pump, set up next to the bed, was not running on the morning of 2/2/26, with approximately 800 ml remaining in a 1000 ml bag of IsoSource 1.5 that was labeled as started at 2:15 a.m. Review of the medical record showed an active order, dated 1/29/26, for Glucerna 1.5 at 75 ml/hr for 20 hours per day, from 4:00 p.m. to 12:00 p.m. the following day, with no special instructions allowing substitution of another formula. The resident was a long-term care resident with traumatic brain injury and dysphagia and was known to have weight loss, relying entirely on G-tube feedings for nutrition. Later that day, the resident was observed sitting in a Broda chair with the G-tube tubing connected, but the pump was turned off, and only about 100 ml less formula was in the bag than at the earlier observation. The Unit Manager stated the tube feeding was not running because it was past the ordered stop time of noon. The DON stated IsoSource should only be used instead of Glucerna if Glucerna was unavailable and that any substitution required NP approval, and she was unsure why there was 400 ml more than expected in the bag, speculating that the night nurse may have spiked a new bag early. However, the LPN who started the tube feeding on night shift stated that the time written on the bag was the time the feeding was actually started. A dietician quarterly assessment note allowing substitution of IsoSource for Glucerna if Glucerna was unavailable was documented later, on 2/2/26 at 2:50 p.m., after the observations.
Failure to Change Suction Canister per Infection Control Policy
Penalty
Summary
Surveyors observed that the facility did not follow its infection prevention and control practices for suction equipment for one resident. On 2/2/26 at 10:34 a.m., a suction canister in Resident B’s room was observed to be approximately half full of yellow-tinged liquid with a layer of yellow sediment settled at the bottom, and the canister was dated 1/13/26. Later that morning at 11:05 a.m., the Executive Director stated that the canister had been changed on 2/2/26, which conflicted with the date on the canister. In the afternoon, surveyors reviewed the facility’s current “Supply Change Out” document, dated 6/2024, which directed that suction canisters and tubing should be changed weekly and as needed, indicating that the observed canister had not been changed in accordance with facility policy. This deficiency was cited under 3.1-18(b) and related to Intake 2731013.
Improper Storage and Handling of Controlled Substances
Penalty
Summary
During a narcotic count observation on the 500 hall medication cart, a Qualified Medication Aide (QMA) was found to have stored controlled substances, specifically Tramadol 50 mg tablets prescribed to a resident, in a manner inconsistent with facility policy and accepted professional standards. The QMA had removed the tablets from their original labeled dispensing container and placed them into multiple pill crusher sleeves, with each sleeve containing 20 half-tablets, some of which were stapled together. The QMA explained that this practice was sometimes done to make counting easier and that pills from different bottles of the same prescription were combined. The Executive Director confirmed that this practice was not in line with facility policy, which requires each drug to be kept in its labeled dispensing container and prohibits transferring drugs from one container to another.
Failure to Respect Residents' Privacy and Dignity
Penalty
Summary
The facility failed to uphold residents' rights to privacy and dignity, as evidenced by multiple instances where staff entered residents' rooms without knocking or announcing themselves. Resident 25 reported feeling disrespected and undignified when staff entered her room or bathroom without knocking, and also mentioned that staff made demeaning comments about odors. During a random observation, two CNAs entered Resident 34's room without knocking, further demonstrating a lack of respect for residents' privacy. Additionally, during a Resident Council Meeting, several residents expressed that staff often entered their rooms without knocking, especially when the call light was on, which made them feel disrespected and deprived of privacy. CNA 14 also entered Resident 46's room without knocking while explaining enhanced barrier precautions. The facility's policy on Residents' Rights, reviewed in January 2025, clearly states that staff should knock and request permission before entering a resident's room, which was not adhered to in these instances.
Medication Labeling and Dating Deficiencies
Penalty
Summary
The facility failed to properly label and date medications on three of six medication carts reviewed, affecting multiple residents. Specifically, Resident 34 had an insulin pen lispro that was not dated correctly, expiring 28 days after opening. Resident 47 had two bottles of latanoprost eye drops without any indication of when they were opened. Resident 5's nasal deep-sea spray also lacked an opening date. Resident 64 had a bottle of Tylenol without a label, and Resident 49's insulin pen lantus was similarly not dated correctly, expiring 28 days after opening. Additionally, Resident 11 had a bottle of Tylenol and a nasal spray, nanogel, both without labels or opening dates. Resident 44 had a bottle of fish oil without a label, and Resident 59's fluticasone nasal spray lacked an opening date. The Nurse Consultant acknowledged the difficulty in managing medication storage, although she indicated that the carts were now correct. The facility's policy on medication expiration requires that multi-dose injections like insulin expire 28 days after opening unless otherwise noted by the manufacturer, and that staff should date the label of any multi-use vial when first accessed.
Infection Control Deficiencies in Nasal Spray Administration and EBP
Penalty
Summary
The facility failed to ensure appropriate infection control measures during the administration of a nasal spray for a resident. During an observation, an LPN was seen administering a nasal spray to a resident without performing hand hygiene or donning gloves, both before and after the procedure. This was in direct violation of the facility's policy on nasal spray instillation, which requires the use of gloves and hand hygiene as part of standard precautions. Additionally, the facility did not maintain consistent and effective infection control practices related to Enhanced Barrier Precautions (EBP) for several residents. Observations revealed that EBP signage was either inadequate or missing, and personal protective equipment (PPE) was not readily accessible in the rooms of residents who required EBP due to conditions such as feeding tubes, amputations, dialysis, pressure ulcers, and indwelling medical devices. Staff interviews confirmed the lack of PPE availability and signage, which contradicted the facility's policy that mandates the posting of EBP signs and the availability of PPE in resident rooms.
Failure to Honor Resident's Preference for Lab Draw Timing
Penalty
Summary
The facility failed to honor a resident's preference regarding the timing of routine lab draws, which led to the resident being woken up too early for blood tests. The resident, who had a history of a kidney transplant and insomnia, expressed dissatisfaction with being disturbed as early as 2:00 a.m. for lab work. Despite communicating his preference to multiple staff members, including a CNA and a QMA, the issue persisted, causing the resident to feel grumpy and have difficulty returning to sleep. Interviews with staff members, including a CNA, QMA, and the Activity Director, confirmed that the resident was not an early riser and disliked early morning lab draws. The Director of Nursing acknowledged that labs were typically drawn between 3:00 and 4:00 a.m. but stated that residents had the right to refuse and that nurses could perform the draws later if necessary. However, the resident's care plans did not reflect any interventions or goals related to his lab work preferences. A review of the resident's lab records showed multiple instances where blood was drawn too early, including several occasions where the timing did not align with the medication schedule for Tacrolimus, an immunosuppressant. The facility's policies on laboratory orders and resident choice emphasized the importance of timely lab draws and supporting resident self-determination, but these were not effectively implemented in the resident's case. The Social Service Director was unaware of the resident's preference until prompted to create a new care plan addressing the issue.
Failure to Initiate New PASARR Screening After New Diagnosis
Penalty
Summary
The facility failed to initiate a new PASARR screening for a resident after a new mental health diagnosis was added to their medical record. The resident, who had diagnoses including bi-polar disorder, dementia, essential hypertension, chronic kidney disease, and major depressive disorder, had a Level I PASARR screening completed earlier in the year, which listed major depression as a diagnosis. However, when a new diagnosis of bi-polar disorder was added, the facility did not conduct a new PASARR screening to determine if a Level II evaluation was necessary. During an interview, the Social Services and Activities Consultant suggested that the resident's dementia diagnosis might not have triggered a Level II screening. The facility's policy requires notifying the state mental health or intellectual disability authority promptly after a significant change in a resident's mental or physical condition, which was not adhered to in this case.
Medication Safety Lapses in Resident Rooms
Penalty
Summary
The facility failed to prevent potential accidents related to medications being left unattended at the bedside for two residents. Resident 60, who has diagnoses including hypertension, arthritis, weakness, and anxiety, was observed sitting in his wheelchair with a cup of pills on a table behind him. The pills were white, orange, and red, totaling approximately eight, and were left unattended despite instructions to the Qualified Medication Assistant not to do so. Additionally, Resident 33 reported to an LPN that there was a pill on the floor next to her bed, which had been there since the night shift. The LPN picked up the unidentified, oblong-shaped, tan pill and disposed of it in the sharps container. The facility's policy on medication self-administration states that residents should always be observed taking their medications and that medications should not remain in the resident's room unless authorized in writing by the attending physician.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for two residents with significant past trauma and PTSD. Resident 25, who has a history of trauma including her father's suicide and physical abuse, was not provided with a personalized care plan to address her mental health needs. Despite her documented struggles with sleep and depression, her care plan lacked updates or revisions to incorporate her trauma history, and the Social Services Director was unaware of her past trauma due to a lack of communication with the psychology group. Resident 65, who has severe PTSD from past sexual assault and experiences as an EMT, also did not receive adequate trauma-informed care. Her care plan did not document her PTSD triggers or interventions, and CNAs were unaware of specific interventions beyond general calming techniques. Her care plan was extensive but lacked individualized interventions for her mental health conditions, and her preference for female caregivers was not documented, leading to her being labeled as refusing care. The facility's policies on trauma-informed and culturally competent care, as well as care plan development and review, were not effectively implemented. The Social Services Director and Regional Nurse Consultant acknowledged the challenges in accessing and updating care plans, suggesting that the CNA assignment sheets should include triggers and interventions for easier access. However, these deficiencies in care planning and communication resulted in inadequate support for residents with trauma histories.
Delayed Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to follow up with pharmacy recommendations in a timely manner for a resident. The resident had diagnoses including palliative care, hypertension, sleep apnea, and pain. On February 5, 2025, the pharmacy recommended a reduction in the resident's aspirin and gabapentin dosages. However, the physician did not respond to these recommendations until February 12, 2025, which was beyond the facility's policy of a 3-day response time. The Director of Nursing (DON) indicated that if there was no response from the physician within 3 days, the recommendation would be sent again. The facility's policy required the DON or designee to ensure the attending physician's review and response within three business days for non-emergent recommendations.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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